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2016 trends

2016 is going to be a challenging year. While more people may have healthcare "coverage" through the Affordable Care Act (ACA), the premiums for this and private coverage will continue to rise with increasing out-of-pocket demands. This may continue to worsen as we see consolidation in the health insurance industry. For those with insurance, high out-of-pocket expenses will keep them from seeking care until they are quite sick. Those who will continue to use the healthcare system will be those without insurance or with inadequate insurance and those with multiple decompensated chronic diseases.

Due to the rise in free-standing EDs, hospitals will see a decrease in compensation from private insurers. While there may be increased coverage through Medicaid expansion, it’s important to remember that just because one has “health insurance” doesn’t mean that he or she has access to care. For example, many providers are not accepting Medicare, and many have determined which insurance companies are contracted at Medicaid rates. Patients "covered" under ACA may have difficulty getting appointments promptly or arranging for follow-up care for existing conditions.

The regions of the U.S. impacted by immigrants from either South America or the Middle East will see an increase in uncompensated and undercompensated care, and may not have facilities for these patients to receive follow-up care. Those who use the healthcare system and cannot pay are quickly being reported to credit bureaus. Therefore, our population will continue to become sicker and seek out primary care in emergency departments with little or no mechanism for follow-up or continuity of care.

The impact this will have on emergency medicine will be an increase in patients with chronic diseases, and undercompensated acute care. This will be further impacted by physician shortages, rising physician costs, and decreased cash per visit. All of these factors will result in increased consolidation by physician management and staffing companies to reduce costs. And, this will not be limited to emergency medicine.

On top of these challenges, emergency medicine and healthcare in general will be held to higher levels of accountability for efficiency (improving flow, decreasing costs and utilization), improved quality (adherence to standards and performance measures), and improved patient experience (better patient satisfaction). CMS and other payors are and will continue to look for ways to provide care to patients in non-traditional and alternative environments to reduce costs (or increase profits).

Next year and beyond, our industry must take a more active role in helping patients receive the right care in the right environment and with the right healthcare resources, which includes using providers at the highest level of their licenses.

The Impact of the 2016 Election on Healthcare

The immediate impact will be uncertainty and thus declining or static stock value for publicly traded companies. On one end of the spectrum, it’s foreseeable that healthcare could be expanded but without regard to the cost of providing this care. Our care has been ranked near the bottom regarding quality compared with other nations, despite having the highest per-capita healthcare costs in the world.

On the other end of the spectrum is an effort to repeal the Affordable Care Act. Some of the most beneficial and impactful changes in healthcare that are sometimes attributed to the ACA have been policies 20 years in the making. A shift from fee for service to a focus on value-based healthcare is not that new of a concept. It’s not realistic to think that the federal government can change our health system in just a few years, and thus any effort to repeal policies of the current administration must be carefully scrutinized. An ideal system is one that has a strong focus on prevention and patient accountability, innovative partnerships to keep patients healthy, and limits interventions that have not demonstrated improved outcomes.

Top Challenges for Hospitals and Physicians in 2016

The top challenges for hospitals next year will be remaining profitable, retaining staff and educating the workforce about why we are doing what we’re doing. For emergency physicians, job security will be an issue, along with adapting to a patient-centric care model, rather than a physician-centric one. Lastly, providing quality care promptly with high patient and employer satisfaction will continue to be a challenge in our field.

In summary, our patient population will grow, with fewer insured, more and multiple chronic conditions, and language challenges demanding more time with fewer resources and decreased reimbursement. However, I don’t believe that this is as grim as it sounds. For those who can be flexible, able to adapt, learn new skills and be patient, there is hope for survival. We will navigate these turbulent times and we will survive. The more we understand the relationships and the resources available among prehospital, in-hospital and post-acute care teams, the better able we will be to meet the needs of our patients.

In the coming years, we will need physician leaders who not only grasp these concepts but can excite the workforce, remove barriers, educate and lead teams, and help ensure the success of physicians and other healthcare professionals so they can focus on the tasks at hand: keeping the needs of the patient as the center of attention while attempting to strike a balance between cost and benefit.

Jerry Allison, MD, MSH, is Regional Medical Director for EmCare in Dallas, Medical Director for AMR-Dallas and Medical Director for Evolution Health’s Medical Command Center and Texas Outpatient Services in Dallas. Dr. Allison was previously Medical Director for EmCare and AMR in California. He has been a paramedic for more than 30 years, served as an EMS Administrator in Ohio and Saipan, and as the Chief Medical Consultant for the California EMS Authority.

The challenges that plagued the healthcare industry this year won’t evaporate come January, but the presidential election may usher in a new set of challenges – and perhaps opportunities, according to EmCare's chief medical officer.

Top Challenges for Hospitals

If a Democrat gains control of the White House in November, not much will change for the healthcare industry, according to Dighton Packard, MD, FACEP, chief medical officer of EmCare. However, if a Republican is elected president and the party wins control of both houses of Congress, there will be “significant changes but it’s impossible to predict that specifics of those changes.”

The top three challenges hospitals will face in 2016, according to Dr. Packard, are:

Hospital-physician alignment, which will be key in the era of value-based purchasing (VBP). Nearly 160 more hospitals will see positive VBP adjustments this year than in 2015, with 475 hospitals righting course from penalty to bonus, according to a recent Modern Healthcare analysis.

Despite the U.S. Senate’s repeal of the sustainable growth rate (SGR) formula, physicians are still losing money each year, according to Dr. Packard. While reimbursement is flat, he explained that physicians and facilities are pressured to improve clinical quality, which puts a larger chunk of physicians’ income at risk each year. “At best, physicians are losing income to inflation, but at worse, it may be much more significant,” said Dr. Packard.

Increased regulatory hassles, including continued ACA-related insurance regulations. Dr. Packard asserts that while few states will move to expand Medicaid, expect changes in the commercial insurance market through the proliferation of high-deductible plans, the loss of balance billing and decreased or static commercial reimbursement rates.

Burnout and staffing challenges will continue to impact the industry. In fact, a recent Mayo Clinic study found that burnout and satisfaction with work-life balance have worsened dramatically. Recognizing the signs of burnout and moving to non-traditional practice environments, like urgent care or telemedicine, can help mitigate the effects on clinicians.For EmCare, Dr. Packard sees many of the same challenges outlined above, but says the company will continue to do what it can to advocate for its physicians.

“We must protect the practices of our clinicians,” said Dr. Packard. “We must maintain their incomes and relieve our clinicians of government hassles. We need to find ways to make our practices more productive and professionally and personally satisfying for our clinical workforce.”

Dighton C. Packard, MD, FACEP, has practiced emergency medicine for more than 30 years. In addition to his duties as Chief Medical Officer for EmCare, Dr. Packard also serves as Chief Medical Officer of Envision Healthcare, the parent company of EmCare Inc. Dr. Packard serves as the chairman of the Department of Emergency Medicine at Baylor University Medical Center in Dallas, Texas, and is a member of the Board of Trustees for Baylor University Medical Center. He received his undergraduate degree from Baylor University, Waco, Texas, and his medical degree from the University of Texas Medical School at San Antonio.

As an election year with the White House still up for grabs, 2016 will likely be less than predictable. However, for Ray Iannaccone, MD, FACEP, FACHE, EmCare’s president, trends in healthcare are a bit easier to predict than the fate of the Oval Office.

The healthcare industry will continue to consolidate. As a result of the Affordable Care Act (ACA), Dr. Iannaccone says hospitals, systems, payors and physician groups will continue to merge to be more financially stable By the end of 2015, Levin Associates predicts the industry will have seen more than 1,312 M&As, surpassing the number of deals in 2014, which had been a landmark year for activity – until now.

The number of employed physicians will rise. Physicians will continue to abandon private practice by joining large physician groups, small local groups or hospitals, predicts Dr. Iannaccone. The need for information technology upgrades, data analysis reporting and relationship building, coupled with the growing need for compassionate end-of-life care, will continue to place stress on private practitioners who often lack the resources necessary to deliver these services. In fact, more than 200,000 physicians in the U.S. are employed, and 75% of medical residents plan to begin their careers as employees of a medical group, hospital or faculty plan, according to the Medscape Employed Doctors Report 2014.

Providers will continue to strive to move the needle on quality. Clinicians and hospitals will continue to pursue solutions to providing higher quality care with increased efficiency. Dr. Iannaccone said that key to this effort will be team-based care, where physicians, nurses, advanced practice providers, technicians, therapists, scribes and other practitioners work together to deliver care.

Expect to see more investment in information technology. “Hospitals and physician practices have been saddled over the last five years with the burden of implementing EMRs, but those investments did little to improve quality and they hurt efficiency,” explains Dr. Iannaccone. “With Meaningful Use in the rearview mirror, providers will invest in ways to modify, enhance and integrate information technology to truly affect change.” A recent report by PriceWaterhouseCoopers, “Medical Cost Trend: Behind the Numbers 2016,” confirms Dr. Iannaccone’s predictions.

Physician engagement will enable new physicians to better commit to work-life balance. “Engagement” may be the latest addition to your department’s buzzwords, but it’s a term that’s here to stay. Defined by Merriam-Webster as “emotional involvement or commitment,” an organization must strive to engage its physicians and non-clinical staff. Only in this way will they be positioned to deliver quality results and compete for the best providers, according to Dr. Iannaccone. “Our workforce is changing. Millennials want to have a say in how care is delivered and policies are developed – and all clinicians should,” explained Dr. Iannaccone. EmCare has taken significant steps to improve the ability of its physicians to contribute to the practice and have input on policies. As a physician-led organization, with Dr. Iannaccone in the president’s role, it recently developed the EmCare Partners Group (EPG) division, which seeks to create a practice culture akin to a physician partnership. "Through our EPG division, we’re piloting ways to provide greater opportunities for clinicians to contribute to the direction of the division in particular and EmCare’s clinical practice in a broader sense,” said Dr. Iannaccone. “I’m excited to see how we can integrate the ‘principles of partnership’ throughout the organization.”

And regarding the election in November, Dr. Iannaccone doesn’t see a repeal of the ACA as a possibility: “The ACA may be imperfect, but our country and our healthcare facilities have invested too much time and too many resources to turn back now. Provisions of the act, however, will continue to be tweaked to more accurately reflect what healthcare is, should be and can be for Americans.”

Ray Iannaccone, MD, FACEP, FACHE, President, joined EmCare when it joined forces with Emergency Medical Associates (EMA) in 2015. Dr. Iannaccone had been the President and CEO of EMA since 2008.